External nose and nasal vestibule: furuncle, vestibulitis, rhinophyma and the danger area of the face
- Topic
Boils and infections of the nose skin are usually minor, but the nose sits in a danger area whose veins drain to the cavernous sinus behind the eyes.
See it in 3D: Nasal cartilages · Nasal bones · Nasalis · Cavernous sinus
What it is
The skin of the external nose and of the nasal vestibule (the hairy entrance of the nostril) has hair follicles and sebaceous glands, so it gets the same problems as other skin: folliculitis, boils, impetigo, rosacea and skin cancer. What makes the nose different is its venous drainage. The veins of the nose and upper lip connect, through the angular and ophthalmic veins, with the cavernous sinus, and they have few or no valves, so an infection squeezed or neglected here can spread backwards and cause a cavernous sinus thrombosis. This page covers how to recognise the common lesions, which signs mean the infection is spreading, and when to refer. The skin diseases themselves have their own condition pages.
Structure
- Nasal vestibule: skin-lined entrance with stiff hairs (vibrissae) and sebaceous glands, up to the limen nasi where the mucosa begins.
- Furuncle (boil): deep infection of one hair follicle; a carbuncle is several boils joined together.
- Vestibulitis: diffuse infection or dermatitis of the vestibule skin, with crusts and fissures; common in children with runny noses and in nose pickers.
- Impetigo: honey-coloured crusts around the nostrils, mostly in children; staphylococcal or streptococcal.
- Rhinophyma: overgrowth of sebaceous glands and connective tissue of the nasal tip and alae in rosacea, mostly in older men.
- Other lesions: herpes simplex, erysipelas, basal and squamous cell carcinoma (sun-exposed skin), cutaneous leishmaniasis, lupus vulgaris (skin tuberculosis) and lupus pernio (sarcoidosis).
Function
- The facial vein begins as the angular vein at the side of the nose and connects with the superior ophthalmic vein, which drains into the cavernous sinus.
- These veins have few or no functional valves, so blood (and infected clot) can flow backwards towards the sinus.
- Inside the cavernous sinus run the internal carotid artery and the abducens nerve; in its lateral wall run the oculomotor, trochlear, ophthalmic and maxillary nerves.
- This is why a thrombosed cavernous sinus gives eye muscle palsies, numbness of the forehead and cheek, and venous congestion of the orbit.
Lesions of the external nose and vestibule
| Lesion | What you see | Cause | What to do |
|---|---|---|---|
| Furuncle | Tender red nodule with a pus point | Staphylococcus aureus | Compresses, topical and oral antistaphylococcal antibiotic; do not squeeze |
| Vestibulitis | Crusts, fissures and redness of the vestibule | S. aureus, runny nose, nose picking | Topical antibiotic and emollient; treat the rhinitis |
| Impetigo | Honey-coloured crusts around the nostrils | S. aureus or Streptococcus pyogenes | Topical antibiotic; oral if extensive |
| Rhinophyma | Bulbous, thick, pitted nasal tip | Phymatous rosacea | Rosacea drugs early; surgery or ablation later |
| Skin cancer | Pearly papule or ulcer that crusts and bleeds | Sun exposure (basal or squamous cell carcinoma) | Biopsy; dermatology or head and neck surgery |
| Cutaneous leishmaniasis | Painless ulcer with raised edge | Leishmania (sandfly bite) | Smear or biopsy and treatment under the MinSalud guideline |
In clinical practice
- Painful red swelling of the nasal tip or vestibule with a yellow point: furuncle. Warm compresses and antistaphylococcal treatment; no squeezing.
- Signs that the infection is spreading: cellulitis of the cheek or eyelids, fever, severe headache, proptosis, chemosis, eye movement pain or palsy, reduced vision, drowsiness.
- Cavernous sinus thrombosis often starts on one side and spreads to the other eye within a day or two, through the venous connections between both sinuses.
- Recurrent boils: look for nasal carriage of S. aureus, diabetes or immunosuppression.
- Rhinophyma can block the nasal valve and hide a basal cell carcinoma; it is treated early with rosacea drugs and later with surgery or ablative procedures.
- Chronic crusting of one vestibule or of the anterior septum that does not settle: look for a septal perforation, leishmaniasis or a tumour.
Next step / Initial management
- Uncomplicated furuncle or vestibulitis: warm compresses, topical mupirocin and, for a boil, an oral antistaphylococcal antibiotic (dicloxacillin or a first-generation cephalosporin; clindamycin or doxycycline if MRSA is suspected).
- Do not squeeze or cut a nasal boil in primary care; a fluctuant boil that does not drain is opened by ENT.
- Refer the same day to the emergency department any nasal or upper-lip infection with eyelid swelling, proptosis, chemosis, eye movement palsy, reduced vision, severe headache or altered consciousness: contrast CT or MR venography, intravenous antibiotics and specialist decision on anticoagulation.
- Recurrent boils: check glucose, look for nasal S. aureus carriage and consider decolonisation.
- Rhinophyma: start rosacea treatment (doxycycline, isotretinoin in selected cases) and make a routine referral to dermatology or ENT for surgery; biopsy any ulcer or fast-changing area.
- Non-healing ulcer or crust of the nose: priority referral (within two weeks) for biopsy.
Test yourself
Think of the answer, then tap the question to see it.
A 30-year-old squeezed a boil on the tip of his nose two days ago. He now has fever, headache, swelling of both eyelids and cannot move his right eye outwards. What is the diagnosis?
Septic cavernous sinus thrombosis from the danger area of the face; the abducens nerve fails first. Same-day referral for imaging, intravenous antibiotics and specialist care.
Why is the nose and upper lip called the danger area of the face?
Its veins connect through the angular and ophthalmic veins with the cavernous sinus and have few or no valves, so infection can spread backwards to the sinus.
Which organism causes most furuncles of the nasal vestibule?
Staphylococcus aureus, often from nasal carriage.
An older man has a thick, bulbous, red nose with large pores and a history of facial flushing. What is it and what underlies it?
Rhinophyma, the phymatous end stage of rosacea; it is not proven to be caused by alcohol.
Elsewhere in DurgiPedia
Connections
See it in 3D4
The structures of Durgical's 3D anatomy where it is found.
Microorganisms1
In Pharmacology5
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Carbuncle (StatPearls Publishing (NCBI Bookshelf), 2023); Staphylococcus aureus Infection (StatPearls Publishing (NCBI Bookshelf), 2026); Cavernous Sinus Thrombosis (StatPearls Publishing (NCBI Bookshelf), 2025); Rhinophyma (StatPearls Publishing (NCBI Bookshelf), 2023); Rosacea (StatPearls Publishing (NCBI Bookshelf), 2023).
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Representative model, for educational purposes only.